Health and Allergies "*" indicates required fields 1Health and Allergy Form2Parental Medical Authorization Health and Allergy FormChild's Name* First Last To best provide for your child, please indicate if there are any health concerns (i.e. vision, hearing, speech, allergies, physical limitations, asthma, etc.)* Yes No Please explain*Does this health concern require our involvement or intervention (i.e. medicine, monitoring, physical aides, etc.)?* Yes No Please explain*Is your child currently under the supervision of a therapist, psychologist, or psychiatrist?* Yes No Please indicate how regularly.* Parental Medical Authorization To the best of my knowledge, my child in in good health and is physically able to participate in all school activities, except as indicated above. I have provided all relevant medical information for my son. I understand that in the event of an emergency and/or special medical treatment, parents will be notified immediately. If the parents cannot be reached, permission is hereby given to Yeshiva Derech HaTorah of Monsey to take whatever steps deemed necessary to ensure the safety and health of my child. This form also gives permission to Yeshiva Derech HaTorah of Monsey to contact the emergency contact and/or my child’s physician when necessary.Print Name* Signature Signature*Date* MM slash DD slash YYYY CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ
